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The decision states face of whether to expand Medicaid to non-disabled, working-age, childless adults—the Affordable Care Act (ACA) primary expansion population— involves tradeoffs. These tradeoffs include higher taxes, reduced spending on items like education, transportation, or infrastructure, or reduced spending on other Medicaid populations such as the disabled, children, or the elderly. The ACA funding formula allows states to pass a much greater share of the costs of covering non-disabled childless adults to federal taxpayers, but the tradeoffs still exist. (Brian Blase, 1/19)

A Washington Post article recently told the story of a mother in Eastern Kentucky who showed up at a small clinic without health insurance and frantic over her 4-year-old daughter’s 103-degree fever and mysterious pain. Stories about poor health and the hurdles in receiving health care have been common throughout Kentucky’s history. But today’s stories often end dramatically differently than those in the past. Thanks to the state’s wise embrace of the Affordable Care Act, the Washington Post reported on the ease the mother experienced in quickly receiving a WellCare card and a diagnosis and treatment for her daughter. (State Reps. Jeffrey Donahue, Derrick Graham, Joni Jenkins, Mary Lou Marzian, Darryl T. Owens, Rita Smart and Jim Wayne, 1/19)

The Supreme Court declined on Tuesday to take a third swing at the 2010 Patient Protection and Affordable Care Act, better known as Obamacare. It was the right call because the case -- Sissel vs. U.S. Department of Health and Human Services -- was built on a fanciful vision of how Congress should operate. Matt Sissel, an artist in Oregon, sued the federal government because he doesn't want to buy health insurance, as required by the ACA. When the Supreme Court upheld the law's individual mandate in 2012, Sissel's initial claims appeared to be dead. But with the help of the conservative Pacific Legal Foundation, he found a clever way to assert a new challenge to the entire law. (Jon Healey, 1/19)

How widespread is the practice of incentivizing mammograms? It is hard to know. Unfortunately, there is no requirement that these incentives be reported, and plan benefits are not typically public. In a brief online search, I found 17 current and recent programs by major employers and health plans. Incentives ranged from $10 to $250, possibly a significant inducement to lower-income women. In choosing among competing guidelines, women are being asked to strike a delicate balance. The trade-offs are complex, and dependent on personal values, like how comfortable with risk you are. Employer and health plan incentives suggest that mammograms are inherently worthwhile and risk glossing over these nuances. (Harald Schmidt, 1/18)

A bitter debate is continuing (including in this issue of JAMA) about the role of clinicians in enabling a good death for the small number of people who wish for assistance in dying. That discussion—about how best to balance respect for the sanctity of human life with the principle of autonomy—has drawn substantial public attention. However, the vital goal almost all people want from medicine is not having a good death but having as good a life as possible all the way to the very end. The evidence indicates that the medical profession is harming vast numbers of patients by neglecting this goal—and that this is not just a US phenomenon but a global one. People everywhere have essential needs aside from just living longer. Medical practices, research, and policies must ensure that clinicians have the skills to understand those needs and have the capabilities to serve them for patients with life-limiting illness. Everyone dies. Death is not an inherent failure. Neglect, however, is. (Atul Gwande, 1/19)

On October 5, 2015, Governor Jerry Brown signed the End of Life Option Act into law, thereby legalizing physician aid in dying in California.1 The significance of this development cannot be overstated. The most populous state in the nation resolved to replace a sesquicentennial aid-in-suicide penal code with a death-with-dignity statute. Other states may soon enact similar statutes. (Ryan P. Clodfelter and Eli Y. Adashi, 1/19)

We frequently hear complaints about how people near the end of life are treated in America. Patients are attached to tubes and machines and subjected to too many invasive procedures. Death occurs too frequently in the hospital, rather than at home, where the dying can be surrounded by loved ones. And it is way too expensive. Each year, the care of dying seniors consumes over 25 percent of Medicare expenditures. Death in America is frequently compared unfavorably with death in other countries. ... But is it actually true that end-of-life care in America is more invasive and expensive than in other countries? (Ezekiel J. Emanuel and Justin E. Bekelman, 1/19)

In 2014, Brittany Maynard, who was dying of brain cancer, took a deliberative decision supported by her family to move from California to Oregon to utilize the Oregon Death with Dignity Act. Highly visible, deeply personal decisions by Maynard and others have influenced social and political discourse around physician-assisted dying (PAD). Although PAD broadly encompasses physician-assisted suicide (PAS) (medicines prescribed specifically for the purpose of being taken by patients to end their lives) and euthanasia (lethal medicines administered by physicians at the patient’s request), states currently only authorize the former. (Lawrence O. Gostin and Anna E. Roberts, 1/19)

Is physician-assisted suicide ever justifiable? —No. ... That we are debating this question of whether physician-assisted suicide (or “physician-assisted death”) is ever justifiable shows how far medicine has shifted toward redefining the role of physician. If the medical profession accepts physician-assisted suicide, it will be declaring decisively that “physicians” are mere providers of services, to be guided only by the desires of the individual patient, the will of the state or other third parties, and what the law allows. The idea of medicine as a profession, which embodies a shared commitment to care for persons who are sick and debilitated so as to restore their health, will quickly fade into memory. Those made vulnerable by sickness and debility, to whom physicians owe their solidarity as physicians, will have much less reason to entrust themselves to physicians’ care. (Y. Tony Yang and Farr A. Curlin, 1/19)

Is physician-assisted death ever justifiable?—Yes. ... Patients with serious illness wish to have control over their own bodies, their own lives, and concern about future physical and psychosocial distress. Some view potential access to physician-assisted death as the best option to address these concerns. Appropriate safeguards, as enacted into law in Oregon, Washington, Vermont, Montana, and (recently) California, create a context in which individual physicians and their patients need not act in secrecy. Patients should be informed about palliative care options (including hospice), have access to expert symptom management, have a predictable time window between making the request and receiving the prescription, and have access to mental health services if needed. (Timothy E. Quill, Anthony L. Back, and Susan D. Block, 1/19)